Gabrijela Kocjan Fine Needle Aspiration Cytology difficult areas of Fine Needle Aspiration Cytology

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  • Gabrijela Kocjan

    Fine Needle Aspiration Cytology

  • Gabrijela Kocjan

    Fine Needle Aspiration Cytology

    With 527 Figures

    123

    Diagnostic Principles and Dilemmas

  • Dr. Gabrijela Kocjan University College London Medical School Dept. of Histopathology Rockefeller Building WC1E 6JJ London

    United Kongdom

    Library of Congress Control Number: 2005937513

    ISBN-10 3-540-25639-3 Springer Berlin Heidelberg New York ISBN-13 978-3-540-25639-7 Springer Berlin Heidelberg New York

    This work is subject to copyright. All rights are reserved, whether the whole or part of the material is con- cerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable for prosecution under the German Copyright Law.

    Springer is a part of Springer Science+Business Media springeronline.com © Springer-Verlag Berlin Heidelberg 2006 Printed in Germany

    The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant pro- tective laws and regulations and therefore free for general use.

    Product liability: the publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature.

    Editor: Gabriele Schröder Desk Editor: Ellen Blasig Typesetting and Production: LE-TEX Jelonek, Schmidt & Vöckler GbR, Leipzig Cover design: estudio calamar, Frido Steinen-Broo, Calamar, Spain

    Printed on acid-free paper 24/3100/YL - 5 4 3 2 1 0

  • To my parents, Hilda and Franc For encouraging my independence

    To Tony and Arabella, For being proud of me

  • Preface

    The urge to write this book arose after years of storing glass slides from difficult cases into plastic folders where they have been breaking and fading. When discussing the- se cases at the weekly teaching for trainee pathologists, some of the observations that arose, made it obvious that experience cannot compensate for methodical approach, careful observation, clinical information and honest conclusion. Hence in writing this book, I had two major aims: firstly, to reiterate the importance of the approach to cytodiagnosis and, secondly, to expose diagnostic dilemmas in some of the most difficult areas of Fine Needle Aspiration Cytology (FNAC).

    FNAC had become a well established diagnostic component in pathology. Within any pathology laboratory, FNAC has its dedicated proponents but also those who are practicing it occasionally, perhaps only to cover the absence of a colleague, or, alongside histopathology, as part of the subspecialty reporting. The differences in expertise often mean that the standard of reporting varies, the latter group being reluctant to ask some of the basic as well as more difficult questions for fear of ap- pearing ignorant. Cytology training is variable in different institutions, depending on the local circumstances. Trainees without any prior experience in cytology may be exposed to difficult FNAC cases early in their career.

    In order to help the approach to FNAC samples for those with and without any prior experience, the first part of this book lists principles of cytological diagnosis. The importance of a methodical approach to interpreting cytological material can- not be overstated. However, cytological interpretation is not merely a mathematical algorithm where numerical values are added up. In majority of cytology cases, the whole is more than the sum of parts: the interpretation of morphological features is complex. It needs careful observation of morphology but also, crucially, it needs to be taken in the clinical context. Without the clinical information, morphology alone may be misleading.

    Chapters on diagnostic dilemmas in FNAC practice discuss potentially difficult morphological features. As well as to educate, the aim of these chapters is to expose difficult areas of diagnosis where FNAC has its limitations. To that end and in line with the developing area of medical litigation affecting all areas of practice, there is a chapter on medico-legal issues associated with FNAC. This is a growing field that has been addressed in a number of legal references but has thus far not been addressed extensively from a cytologicl standpoint.

    In preparing this manuscript, I would like to thank, first of all, my patients for allowing me to use their clinical histories and photomicrographs. I would also like to thank my colleagues in the Department of Histopathology, University College Lon- don, in particular Dr. Mary Falzon for their help in sharing some of the diagnostic dilemmas presented in this manuscript. The ability to share problems with clinicians and fellow pathologists is the essential requirement for ensuring a good night’s sleep and one’s professional reputation. I would also like to thank my clinical colleagues by their supportive approach to cytology in sending their patients for FNAC. The ex-

  • VIII

    perience I have accumulated on these sound clinical grounds had been shared with generations of postgraduate trainee pathologists. I thank them for being a source of inspiration through curiosity and enthusiasm. Many went on to become dedicated cytopathologists and made me immensely proud of them. I would also like to give special thanks to Eva Kauerova for her help in the past five years.

    I hope that you, the reader, will use this book in your daily practice, if only to find that there are no straight answers to difficult questions.

    G Kocjan September 2005 London

  • Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII

    Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IX

    Introduction and Historical Perspective . . . . 1

    References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

    FNAC Technique and Slide Preparation . . . . 7

    2.1 Informed Consent. . . . . . . . . . . . . . . . . . . . . . . . . 7

    2.2 Location of the FNAC Procedure . . . . . . . . . . . . 8 2.2.1 The FNAC Clinic. . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.2.2 Inpatient FNAC. . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.2.3 Image-Guided and Other FNAC

    Procedure Locations. . . . . . . . . . . . . . . . . . . . . . . 12

    2.3 The Importance of the Aspirator . . . . . . . . . . . 14

    2.4 Aspiration Techniques . . . . . . . . . . . . . . . . . . . . 15 2.4.1 Suction FNAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.4.2 The Capillary Method . . . . . . . . . . . . . . . . . . . . . 16

    2.5 Slide Preparation. . . . . . . . . . . . . . . . . . . . . . . . . 17 2.5.1 Conventional Preparations . . . . . . . . . . . . . . . . . 17 2.5.2 Liquid-Based Preparations . . . . . . . . . . . . . . . . . 18 2.5.3 Cell Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

    2.6 Fixation Techniques . . . . . . . . . . . . . . . . . . . . . . 19 2.6.1 Air Drying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2.6.2. Alcohol Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . 20 2.6.3 Transport Medium . . . . . . . . . . . . . . . . . . . . . . . . 20

    2.7 Staining Methods . . . . . . . . . . . . . . . . . . . . . . . . 20 2.7.1 Papanicolaou Staining . . . . . . . . . . . . . . . . . . . . . 20

    2.7.2 Romanowsky Staining . . . . . . . . . . . . . . . . . . . . . 22 2.7.3 Other Stains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

    2.8 Ancillary Techniques . . . . . . . . . . . . . . . . . . . . . 23 2.8.1 Cytochemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.8.2 Immunocytochemistry . . . . . . . . . . . . . . . . . . . . 24 2.8.3 Molecular Markers in Cytology . . . . . . . . . . . . . 26

    2.9 Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

    References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

    Diagnostic interpretation of FNAC material . . . . . . . . . . . . . . . . . . . . . . . . . . 35

    3.1 Slide Background . . . . . . . . . . . . . . . . . . . . . . . . 35 3.1.1 Cystic Background . . . . . . . . . . . . . . . . . . . . . . . . 39 3.1.2 Inflammatory Background . . . . . . . . . . . . . . . . . 40 3.1.3 Necrotic Background . . . . . . . . . . . . . . . . . . . . . . 42 3.1.4 Myxoid and Mucinous Background. . . . . . . . . . 42 3.1.5 Lymphoid Background. . . . . . . . . . . . . . . . . . . . . 43 3.1.6 Other Background Features . . . . . . . . . . . . . . . . 43

    3.2 Cell Arrangement . . . . . . . . . . . . . . . . . . . . . . . . 44 3.2.1 Clusters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.2.2 Sheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.2.3 Single Cells. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 3.2.4 Papillary Arrangement. . . . . . . . . . . . . . . . . . . . . 47 3.2.5 Other Features. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

    3.3 Cellular Features: the Nucleus. . . . . . . . . . . . . . 49 3.3.1 Nuc